(in student health centers, hospitals, long term care, rehabilitation and home health agencies) NOTE: Paper records may be destroyed after scanning or microfilming, with digital and microfilm versions replacing the original for retention purposes. Record RDA Content Minimum Retention Notes Reason for Proposed Time 1. Health Center Student Medical Records 22235 All medical and psychiatric information (college entrance physical report doctor & nurse notes, lab and x-ray reports, any and all correspondence) regarding student health or anyone treated at campus health centers. 2. Patient Medical Record 22236 All components of patient medical/clinical record paper or electronic in all types of facilities (hospitals, long term care, rehabilitation and home health agencies) including Email with patient relevant to care and treatment (print and retain delete from electronic storage). 7 years This does not apply to patient medical records maintained at University Medical Centers. 21 years, but not less than 1 year after any minor patient reaches the age of 21 years Sufficient to needs; min. 8 NYCRR 29.2. 10 NYCRR 405.10(a)(4) 8 NYC RR 29.2 10 NYCRR 405.10 (a) (4) min 6 years 1
3. Tracings, recordings which are not contained in the patient medical record 22237 EMG, EEG, Photographs, Fetal Heart Monitor Strips, EKC/ECG, Holter Monitor, Stress Test (paper or electronic), Radiology or Nuclear Medicine films, radiology images, films, scans, other images, tracings and recordings, that have not been incorporated into the medical record (paper or electronic). 21 years or as long as the patient's medical record is maintained, whichever is longer. Necessary for consistency and sufficient to and needs 4. Mammogram 22238 Mammography films, images and reportsbaseline and subsequent Paper or electronic 21 years Paper records may NOT be destroyed. 10 NYCRR 16.22 (b)(2) 5. Testing Tools 22239 e.g. IQ or vocational tests Until no longer needed Sufficient to 6. Clinical and Anatomical Pathology, Transplant 22240 Records of pathology and transplant anatomic and nonanatomic excluding test requests 21 years 42 CFR 486.330 min 7 years transplant records 7. Correspondence from other providers not merged into medical record 22241 Records of other providers which are Retain as long as retain Necessary for 2
not incorporated in to medical record and no care and treatment decisions based on material correspondence in nature only medical record consistency. 8. Patient transfer records and logs 22242 All information regarding patient transfers that is not incorporated in to the patient medical records including logs and forms 10 years 42 CFR 489.20 (r) (1) min 5 years 9. Indexes 22243 Master Patient Index, Diagnostic and Procedures index, physician index, OR case index, Death index a. For campus student health centers. 10 years Sufficient to needs and for research purposes b. For hospitals, long term care, rehabilitation and home health agencies. PERMANENT Sufficient to needs and for research purposes. 3
10. Logs of Patient Treatment and Admissions 22244 Scheduling, activity or other logs recording patient treatment and/or admissions. 11. Work Schedules and On-Call Schedules/Logs 22245 On call schedules of physicians and schedules of hospital personnel 10 years Sufficient to 6 years Sufficient to 12. Birth Registry 22246 Registry of all births PERMANENT 13. Cytogenetics 22247 Cytogenetics information and counseling records 14. Reproductive Tissue/Artificial Insemination/Implantation 22248 all records relating to reproductive intervention 15. Transfusion and Blood Product Records 22249 Records related to blood products or derivatives, allogenic and auto transfusion, cytapheresis and hematopoietic proginator cell banks 25 years Necessary to patient 25 years Necessary to patient 21 years Necessary for consistency. 16. Requisitions for Diagnostic tests 22250 Paper and electronic 10 years Sufficient to 4
17. ER Diversion Records 22251 Records indicating diversionary status of general emergency department 6 years Sufficient to 18. Pharmacy Records of Controlled Substance Inventory, Disposal, Orders and Prescriptions 22252 Paper and electronic 5 years Education Law 6810.5 of & Public Health Law 3370.1 19. HIPAA-Accounting of Disclosures Log 22253 Records disclosures of medical record 6 years 45 CFR 164.528 8 (a) (1) min 6 years 20. Release or Disposal of Human Remains 22254 All records relating to release or disposal of remains following death 21 years following release or disposal Sufficient to 21. Environment of Care environment and equipment 22255 All records relating to clinical engineering, environment of care incidents, training, compliance and testing, maintenance and quality checks of life safety equipment 10 years 10 NYCRR 405.24 (c) (2) min 3 years 22. Medical Device Reporting 22256 Adverse Event Files 21 years 21 CFR 803.18 (c) 23. Financial Statements and Records 22257 All records which form the statistical and factual reports by the facility with the 10 years or 6 years following a disputed audit, 31 USC 3731(b). 5
DOH and Medicare, including general hospital financial statements and patient billing records. 24. Medical Staff Credentialing 22258 All applications and supporting material relating to credentialing and privileges whichever is later 100 years Keep for lifetime of applicant. 25. Medical Staff Bylaws/Governing Body Records 22259 All records of medical staff governance and governing body functions. 26. Hospital Policies and Procedures 22260 Administrative and Clinical written policies and procedures PERMANENT PERMANENT Sufficient to NYS Schedule [ 90208 Major Administrative Policies and Procedures.] Sufficient to 27. Hospital and Medical Staff Committee Minutes 22261 PERMANENT 28. Patient Complaints and Grievances 22262 Correspondences and investigation material, grievance committee records 21 years Sufficient to 6
29. Incident Reports 22263 Relating to patient care, facilities or other events. 30. Infection Control 22264 Relating to events, protocols, or other. 21 years Sufficient to 10 years Sufficient to 31. Quality Assurance Records /Peer Review/Quality Improvement/Patient Safety Evaluation System/Patient Safety Work Product Records 22265 a. Quality assurance plan, including staff privileges review procedures: PERMANENT b. Relating to quality of care provided by individual hospital staff members. c. Relating to quality of care provided individual patient, when not duplicated in medical 10 years after termination of employment or medical staff membership. Retain as long as medical case record. including minutes, reports, patient safety work product, root cause analysis, and all other documentation created during a quality assurance/quality improvement process Health 466] 7
case record: d. Relating to more than one patient: Retain as long as all relevant medical case records are retained. e. Written authorization from providers to disclose patient safety work product. 6 years after the data of the 42 CFR 3.206 32. Approvals and registrations relating to radiological equipment and materials 22266 a. Approval to possess or use radioactive materials, received from New York State Department of Health, and related records. b. Registration of radiationproducing equipment with New York State Department of Health, and related records. 3 years after facility no longer possesses or uses radiological materials 2 years after expiration or renewal Health 251] 8
33. Radiation-exposure records for an individual 22267 a. Records of diagnostic misadministrat ions. 3 years b. Records of therapeutic misadministrat ions. c. Radiationexposure data for an individual, including records of radioactive material deposited or retained in body. 6 years 0 after individual attains age 90 Health 252] 34. Records of occupational doses for an individual using radiation-producing equipment or radiological materials 22268 a. Annual or other summary occupational dose records. b. Detailed occupational dose records. 0 after individual attains age 90 0 after annual or other summary record containing this information is produced Health 888] c. Records of 0 after individual 9
prior occupational dose. attains age 90 d. Records of planned special exposures. 0 after individual attains age 90 35. Radiation equipment testing and inspection records 22269 a. Regulatory inspection and audit records, including master summary record and "index card." b. Equipment accuracy testing records, including surveys, calibrations, measurements, and quality control tests. 6 years after equipment no longer in use 3 years Health 253] 36. Records of disposal, theft, loss, or excessive release of radiation 22270 a. Records concerning theft or loss of radiation source, excessive release of radiation, or PERMANENT Health 254] 10
excessive exposure of individual to radiation, including documentatio n of notification. b. Record of disposal by burial in soil. PERMANENT c. Records of authorized transfer or receipt, or issue and return of radiation source or radioactive materials, or disposition by incineration or release into sanitary sewer system. 6 years 37. Radiation program safety records 22271 a. Records documenting provisions of program. b. Audits and other reviews of program content and 3 years after program ceases to exist 3 years Health 889] 11
implementation. c. Records documenting specific instructions given to workers. 3 years 38. Reports to Regulatory/Accrediting Agencies/Entities 22272 JCAHO, NYPORTS, CMS, other 10 years or 10 years after closure of matter, whichever is later. Sufficient time for response to regulatory agencies. 12